APHA 140th Annual Meeting & Expo, October 27-31, 2012, San Francisco, CA Body weight control and tobacco smoking among adolescents: a prospective study Melinda Pénzes M.D.1, Edit Czeglédi M.A.2, Péter Balázs M.D., Ph.D1, Kristie L. Foley Ph.D3 1 Semmelweis University Budapest, Institute of Public Health 2 Eötvös Loránd University Budapest, Doctoral School of Psychology, Institute of Psychology 3 Davidson College, Medical Humanities Program, NC

Presenter Disclosures “No relationships to disclose” Dr. Melinda Penzes (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: “No relationships to disclose”

Funding This study was made possible by Grant Number 1 R01 TW007927-01 from the Fogarty International Center, the National Cancer Institute, and the National Institutes on Drug Abuse, within the National Institutes of Health (NIH). „Increasing Capacity for Tobacco Research in Hungary” 2008-2013

Introduction I. Body weight and current smoking is inversely associated among adults. Widespread belief among adults as well as adolescents that tobacco smoking controls body weight. Does smoking have weight-loss effect in adolescence? Views are controversial about the relationship between smoking and adolescents’ body shape weight concerns belief that smoking controls weight.

Introduction II. Findings about adolescent smoking and body weight-related factors Association with Smoking By gender Overweight Positive or no Inconsistent Perceived overweight May play a role in initiation and maintenance of smoking Mainly girls Weight concerns Positive association Dieting behavior Clear positive association Girls Belief that smoking controls weight More prevalent among smokers

X Purpose Body Mass Index Satisfaction with body and appearance Desire for change body shape Weight control belief of tobacco smoking Associated with tobacco smoking in adolescence? Differs by gender? Change in the strength of possible association? Play role in the initiation of smoking? X

Methods – Survey „Longitudinal Study of Tobacco Smoking and Body Weight Management among Adolescents” Prospective cohort study The capital and 5 Hungarian metropolitan cities Baseline (2010.) and follow-up survey (2011.) Randomly selected elementary and high schools 6th and 9th graders at baseline Self-administered questionnaire annually Body weight, body height measurement by school nurses n=1,389 Hungary Miskolc Győr Budapest Debrecen Szeged Pécs

Methods – Measurements Smoking status Current smokers: were smoking in the past 30 days Non-smokers: were not smoking in the past 30 days or did not try smoking Objective Body Mass Index Calculated from measured body weight and body height (kg/m2) Short form of the Smoking Consequences Questionnaire (MG. Myers, 2003) Appetite-Weight Control Subscale Cronbach α: Wave 1: .91; Wave 2: .89 Subscale was dichotomized using median split Low agreement with the belief that smoking controls weight High agreement with the belief that smoking controls weight

Methods – Measurements Contour Drawing Rating Scale (MA. Thompson & JJ. Gray, 1995) 9 male and female front-view contour drawings Current and ideal figure Current – ideal discrepancy No discrepancy Desire thinner body Desire more robust body Body and Appearance Satisfaction Scale (N. Kiss, 2008) 6 items (satisfaction with body weight, height, muscularity, face, body shape, overall appearance) Cronbach α: Wave 1: .85; Wave 2: .86 Subscale was dichotomized using median split Less satisfied / more satisfied with body and appearance

Methods – Analyses Chi-squared tests Independent samples T-tests Multivariate binary logistic regression analyses (controlled for grade, parental and peer smoking) SPSS 17.0; CI 95%; p<.05 Predictors Wave 1 Smoking status by gender Wave 1 Model 1 Predictors Wave 2 Smoking status by gender Wave 2 Model 2 Predictors Wave 1 Smoking initiation at Wave 2 by gender Model 3

Results – Demographics SURVEY 1. (2010.) 2. (2011.) GRADE 6. 9. Total 7. 10. Sample (n) 807 1401 2208 740 1341 2081 In follow-up (n) 525 864 1389 Mean age (years) [SD] 12.0 [0.61] 15.0 [0.62] 13.9 [1.57] 13.0 [0.65] 16.0 [0.61] 14.9 [1.59] Range 11-15 14-17 11-17 12-17 14-19 12-19 Gender: boys: 45.4%; girls: 54.6% Type of settlement: capital (Budapest): 58.7%; metropolitan cities: 41.3% Type of school: Elementary school: 37.8% High school: 24.6% Vocational school: 37.7%

Results – Prevalence of smoking Tried smoking at Survey 1 and 2 by gender and grade Grade 6th to 7th Boys: χ2(1)=16.24, p<.001 Girls: χ2(1)=28.24, p<.001 Grade 9th to 10th Boys: χ2(1)=30.05, p<.001 Girls: χ2(1)=21.62, p<.001

Results – Prevalence of smoking Current smokers at Survey 1 and 2 by gender and grade Grade 6th to 7th Boys: χ2(1)=2.09, ns Girls: χ2(1)=10.42, p=.001 Grade 9th to 10th Boys: χ2(1)=24.07, p<.001 Girls: χ2(1)= 27.18, p<.001

Results – Prevalence of smoking Survey 1 Survey 2 Change χ2 test Experimenters (%) 44.0 55.8 11.8 77.95*** Current smokers (%) 18.7 26.6 7.9 56.53*** ***p< .001 GRADE 6th7th 9th10th Total Became new smoker (%) 4.8 15.2 11.2 Quit smoking (%) 1.9 4.3 3.4

Results – Smoking status and BMI kg/m2 p=.006 Cohen d=0.34 p=.001 Cohen d=0.37 p=.014 Cohen d=0.29 ns Cohen d=0.16 Means and 95% confidence intervals

Results – Smoking status and weight control belief of smoking p=.008 Cohen d=0.29 p<.001 Cohen d=0.47 p=.006 Cohen d=0.27 p<.001 Cohen d=0.42 Means and 95% confidence intervals

Results – Smoking status and satisfaction with body and appearance Cohen d=0.19 p=.004 Cohen d=0.27 p=.092 Cohen d=0.16 p=.001 Cohen d=0.26 Means and 95% confidence intervals

Results – Smoking status and desire for change body shape χ2(2)=8.11 ns p=.013 χ2(2)=8.72 ns

Results – Logistic regression analysis Results – Logistic regression analysis predicting current smoking at Wave 1 Predictor Boys Girls OR 95% CI Higher Objective BMI 1.11* 1.01-1.23 1.05 0.98-1.13 Less satisfied with body and appearance 1.54 0.80-2.96 0.97 0.53-1.76 Discrepancy of current-ideal body shape Desire thinner body 0.63 0.25-1.58 1.21 0.58-2.53 Desire more robust body 2.20+ 0.99-4.87 1.51 0.65-3.51 Agreement with the belief that smoking controls weight 1.84+ 1.00-3.39 1.73* 1.01-2.95 Nagelkerke R2 31.5% 34.2% * p < .05; + p < .10

Results – Logistic regression analysis Results – Logistic regression analysis predicting current smoking at Wave 2 Predictor Boys Girls OR 95% CI Higher Objective BMI 1.04 0.94-1.16 1.03 0.95-1.11 Less satisfied with body and appearance 1.00 0.51-1.98 0.57+ 0.31-1.05 Discrepancy of current-ideal body shape Desire thinner body 1.18 0.44-3.19 0.95 0.47-1.90 Desire more robust body 1.55 0.67-3.61 0.82 0.33-2.06 Agreement with the belief that smoking controls weight 1.29 0.67-2.47 2.26** 1.29-3.95 Nagelkerke R2 41.3% 43.7% ** p < .01; + p < .10

Results – Logistic regression analysis predicting Results – Logistic regression analysis predicting smoking initiation for Wave 2 Predictor Boys Girls OR 95% CI Higher Objective BMI 1.07 0.95-1.21 0.96 0.88-1.06 Less satisfied with body and appearance 1.03 0.46-2.28 4.10** 1.73-9.67 Discrepancy of current-ideal body shape Desire thinner body 1.34 0.46-3.93 0.67 0.29-1.56 Desire more robust body 1.21 0.42-3.46 0.54 0.19-1.50 Agreement with the belief that smoking controls weight 0.72 0.34-1.54 0.52-1.80 Nagelkerke R2 14.7% 13.3% ** p < .01

Summary At baseline, the belief that smoking controls body weight predicted smoking especially among girls. Boys who desired more robust bodies were also more likely to smoke. After a year, weight control beliefs remained significantly associated with smoking, but only among girls. At follow up, the prevalence of smoking increased remarkably especially among higher graders and 11.2% of participants became smoker. Girls’ dissatisfaction with body image represented risk for starting smoking, but self-assessment of body image among boys was unrelated to smoking at follow-up.

Conclusions The weight control belief of smoking did not play a role in smoking initiation. The weight control belief began to recover consciousness among those adolescents who were already smokers. Danger lies in the fact that later in life this belief may play a role in not quitting smoking. Tobacco prevention programs for adolescents should be differentiate by gender, should emphasize the adverse effects of smoking as a weight control method as well as stressing healthy methods of healthy weight management.

References Kiss N. The relationship between self-esteem and body image dissatisfaction in adolescence. Unpublished master’s thesis, Eötvös Loránd University, Budapest, Hungary. Myers MG. et al. Constructing a short form of the Smoking Consequences Questionnaire with adolescents and young adults. Psychol Assess. 2003 Jun;15(2):163-72. Thompson MA, Gray JJ. Development and validation of a new body-image assessment scale. J Pers Assess. 1995 Apr;64(2):258-69.

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